Risk Management Professional

Risk Management Professional – Humana

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$65,000.00/yr - $88,600.00/yr

The Claims Risk Management Professional is responsible for ensuring payment quality of claims in accordance with TRICARE policy requirements. This role involves reviewing pre‑payment, high‑dollar claims to assess payment accuracy and identify potential claim payment risks. The incumbent will provide accurate, actionable, and thorough feedback by completing high‑dollar pre‑pay reviews daily, sharing audit results with operational areas to help mitigate organizational risk and support quality‑related goals.

The incumbent will exercise discretion and judgment in prioritizing requests, interpret and adapt procedures, and work under limited guidance, leveraging previous experience and organizational knowledge.

• Utilize strong analytical, technical, and communication skills, and a comprehensive understanding of TRICARE policies, to conduct daily high‑dollar claim quality audit reviews. Responsibilities include making approval and processing determinations for payment release, conducting focused claim studies, and performing duplicate claim detection through the DHA Duplicate Claims System (DCS).
• Research and review claims for internal focus audits to identify potential payment error risks, areas for improvement, and possible system issues. These activities support the mitigation of financial risk and help ensure quality standards are met for quarterly and annual government audits, in accordance with organizational procedures and TRICARE policy requirements.
• Develop and recommend controls and cost‑effective approaches to minimize claims processing risks.
• Perform advanced administrative/operational/customer support duties that require independent initiative and judgment.
• Assist in special projects as directed by Department Management.

• U.S. citizenship (required by Department of Defense contract).
• Successfully receive interim approval for government security clearance (NBIS – National Background Investigation Services).
• HGB is not authorized to do work in Puerto Rico per our government contract; candidates living in Puerto Rico are not eligible.
• 2 years of TRICARE claims experience, including professional and institutional claims reimbursement.
• Strong knowledge of TRICARE policy and claims processing.
• Ability to work 8‑hour shifts between 7 a.m. – 6 p.m. E.T.

• Bachelor’s degree.

• Minimum download speed of 25 Mbps and upload speed of 10 Mbps recommended; wireless, wired cable or DSL connection is suggested.
• Satellite, cellular and microwave connections may be used only if approved by leadership.
• Associates living and working from home in California, Illinois, Montana, or South Dakota will receive a bi‑weekly payment for their internet expense.
• Humana will provide home or hybrid home/office associates with telephone equipment appropriate to meet business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

While this is a remote position, occasional travel to Humana’s offices for training or meetings may be required.

40 hours per week

Humana, Inc. offers competitive benefits that support whole‑person well‑being, including medical, dental, vision, 401(k) retirement savings plan, paid time off, short‑term and long‑term disability, life insurance, and many other opportunities.

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. Humana also takes affirmative action under Section 503 of the Rehabilitation Act and VEVRAA to employ and advance individuals with disability or protected veteran status, basing all employment decisions only on valid job requirements.